Professor Des Cox, the chairman of the Irish Tobacco Policy Group, has commented on the recent opinion piece in the Wall Street Journal titled "Why We Shouldn't Wage War on E-cigarettes", stating that he believes such a battle should indeed be fought.
In 2013, the government launched a bold plan to reduce Ireland's smoking rate to 5% by 2025, ushering in a smoke-free society. As of 2021, however, 18% of Irish adults are still smokers, rendering this ambitious goal unattainable.
Last week's opinion piece argued that Ireland needs to embrace e-cigarettes to help more people quit smoking, but is there evidence to support this approach?
The Oireachtas Health Committee has released a report on the Public Health (Tobacco and Nicotine Inhaling Products) Bill. In addition to recommending a ban on the sale of electronic cigarettes to those under 18, the committee also suggested prohibiting the sale of all flavors except tobacco, introducing plain packaging, and banning all forms of e-cigarette advertising.
Teenagers
The first issue to be addressed is the relationship between electronic cigarettes and youth. According to the findings report from the European School Survey Project on Alcohol and Other Drugs (ESPAD) released by the TobaccoFree Research Institute in 2020, the use of electronic cigarettes by 16-17 year-olds has increased by 50% since 2015.
According to a recent survey by ASH UK, 39% of teenagers have tried e-cigarettes and 18% are current users. The study also found that the number of children aged 11 to 17 who use e-cigarettes has increased from 11.2% in 2021 to 15.7% in 2022.
Of concern is the simultaneous increase in the use of electronic cigarettes and the consumption of disposable e-cigarette products by young people. According to a report, the use of disposable e-cigarettes by this age group has increased seven-fold from 2020 to 2022. Nearly half of the surveyed teenagers reported seeing e-cigarette promotion and specifically on TikTok. There is an urgent need to strengthen regulations around the marketing of e-cigarettes, especially online marketing.
Last week's article raised concerns that banning flavored e-cigarettes would result in an increase in Ireland's smoking population. However, there is no publicly available evidence to support this claim. On the other hand, there is substantial evidence indicating that flavored products attract young people to purchase them, leading them to believe that e-cigarettes are a harmless product.
Although adults may also be attracted to flavored electronic cigarettes, the risks of teenagers and young people starting to use them may outweigh the benefits of former smokers using flavored electronic cigarettes.
Last week's article claimed that vaping is a gateway to smoking. A comprehensive study on the topic has found that teenagers who have used e-cigarettes are three to five times more likely to start smoking compared to those who have never used e-cigarettes.
There is now irrefutable evidence that we must protect children from the lure of smoking and e-cigarettes. Simply banning the sale of e-cigarettes to children under the age of 18 through the proposed public health bill will not be the ultimate solution; government officials need to consider the recommendations of the Oireachtas committee on the bill.
Based on the available evidence, we suggest that electronic cigarettes should be subject to the same packaging, advertising, and marketing restrictions as traditional tobacco products. Ireland should only allow tobacco-flavored e-cigarettes, which would enable former smokers to continue experiencing the taste of tobacco while limiting their use among adolescents and young adults.
Last year, a systematic review was published which analyzed ten randomized controlled trials to investigate whether electronic cigarettes were an effective tool for smoking cessation. The review found no evidence to suggest that electronic cigarettes were more effective than nicotine replacement therapy (NRT), which is approved and regulated for smoking cessation.
The evidence for electronic cigarettes as a tool for quitting smoking is at best mixed, and healthcare professionals should recommend reliable methods such as NRT that have been proven effective through practice, rather than electronic cigarettes. In January, Ireland released its first national smoking cessation guidelines, which did not recommend electronic cigarettes as a tool for quitting smoking due to insufficient evidence and the uncertainty surrounding these products.
Best advice.
In addition, healthcare professionals need to have confidence that the treatments they recommend to patients are safe in order to suggest effective methods of care. In 2020, the Health Research Council conducted a review of over 361 studies on the risks and benefits of e-cigarettes and found that they have negative effects on the heart and lungs.
Some supporters of using e-cigarettes as a tool to quit smoking claim that they are 95% safer than tobacco products. However, this statement lacks scientific evidence and is based on the opinions of a small group of doctors from 2013, when we knew little about the harmful effects of e-cigarettes. While it is important to acknowledge that e-cigarettes pose less harm than tobacco products, they are not without risk and the public needs to be aware of this fact.
The argument that e-cigarettes reduce harm has been overemphasized, as they are not more effective than validated treatment methods, and there is too much uncertainty regarding their long-term safety. Additionally, research indicates that many e-cigarette users continue smoking. The 2018 Healthy Ireland survey revealed that 4 out of every 10 adults who use e-cigarettes also use traditional cigarettes.
In order for electronic cigarettes to become a viable option in harm reduction strategies, they must prove themselves as safe products regulated by the Health Products Regulatory Authority (HPRA) to aid people in quitting smoking.
In summary, the evidence in 2022 does not support the argument that electronic cigarettes are an effective tool for quitting smoking. Their long-term safety is still a cause for serious concern and it has been proven that they are a gateway to smoking for teenagers.
Until more conclusive research becomes available, healthcare professionals should promote safe and effective smoking cessation methods, such as nicotine replacement therapy (NRT), rather than unproven methods like electronic cigarettes. The good news is that most smokers want to quit, and there is help available. The HSE's www.quit.ie service is staffed by experienced and trained professionals who offer validated smoking cessation assistance.
Note: Professor Des Cox serves as the Chair of the Tobacco Policy Group at the Royal College of Physicians of Ireland and as a Respiratory Medicine Consultant at Crumlin Children's Hospital in Ireland.
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